International Medical Graduates
Suhail A. Shah, MBBS
Associate Chief of the Hospitalist Program
North Shore University Hospital
Manhasset, New York
Hospitalism is a rapidly developing concept that has been widely accepted and used throughout the United States. Much of Europe has been using internists in a model more or less like the hospitalist in the U.S. for years. In the U.S., the hospitalist is defined as an internist whose "major" time commitment is towards inpatient care, with varying proportions cited in different states.
The hospitalist era in the U.S. was brought about by a radical shift in thinking. The main reason may have been financial. In these days of managed care and ever decreasing reimbursements, the internists trip from his or her office to the hospital for one or two inpatients is not financially worthwhile. Also, the hospitalists’ constant presence in the hospital and their exposure to the relatively sicker inpatient is a powerful stimulus for improvement; and probably more efficient care of the hospitalized patient. Hospitalists have in the past been sub-specialists but now mainly comprise doctors just out of residencies.
Some key points concerning hospitalists.
- The degree of inpatient-to-practice-based work varies widely. Some larger internist group practices hire a hospitalist to do all their inpatient work exclusively; whereas some use each internist as a ‘rotating hospitalist’ for specific periods of time.
- The remuneration varies widely, expectedly with geographical locations with pay scales inversely proportional to the proximity of the hospital to larger cities. Some hospitalists are reimbursed on the basis of an incentive plan.
- It is not entirely clear if the hospitalists ever "pull their weight" in creating enough revenue through their own billing to cover their salary. However, indirectly, they probably do, through their effect on decreased utilization of resources through shorter length of stay. In addition, if they employ a hospitalist, a group of internists can save time and bill more patient visits in the office setting, which mostly are reimbursed at higher rates.
- Is it a sustainable career for residents, short term or long term? In my experience, I have seen several residents join large group practices and work as their hospitalists for a year before moving on to pure out-patient practice. It is probably too early to judge, since the concept is very new.
- A frequent concern is of "burnout" Being more or less constantly "on" for admissions and in-patient work. However, I and at least three of my colleagues have been hospitalists for more than 3 years now with no significant sign of immediate mental decompensation!
- What about satisfaction? In my experience, there is ample satisfaction involved with taking part in the treatment and care of relatively sick patients and getting them back on their feet and mending. There however are concerns with not having the opportunity to follow up with these patients again and sometimes a "hiatus" in satisfaction.
- What about transfer of care? A major contentious point has been whether primary care providers can effectively transmit information to the hospitalist and vice versa. These concerns can easily be addressed by effective communicating tools, e.g., the phone, fax, email, regular mail. Also invariably there is some transfer of care involved (e.g., on weekend coverage arrangements) even if hospitalists are not used.
- What about follow up or liability issues? Certain patients who are non-compliant with follow up or do not have either insurance or doctors pose a challenge. For example, if there are studies or blood tests to be done on an outpatient basis, who will order them and then check the result? The case of prothrombin times monitoring on patients discharged on coumadin is a typical example. The hospitalist referring these cases to the appropriate out patient setting, e.g., medical clinics, faculty practice out patient practices (if available) can solve some these concerns.
Overall, hospitalism is rapidly emerging as one of the fasting growing fields of internal medicine and I believe, provides a satisfying and enriching experience for any doctors who choose to immerse themselves in it.
I completed my residency in Internal Medicine from the Nassau County Medical Center and then finished a year as chief resident in 1997. Since July 1997, I have been working as a hospitalist in North Shore University Hospital at Manhasset. I was appointed Associate Chief of the Hospitalist Program in July 1998. Currently we are 5 hospitalists in our program and are looking to expand in the future. We are involved in a continuing research activity of looking at various parameters of patient care and hospitalist issues.
Suggested further reading
1) Wachter RM, Goldman LM. "The Emerging role of ‘hospitalists’ in the American Health Care System." New England Journal of Medicine. 1996; 335: 514-7.
2) Wachter RM. "An Introduction to the Hospitalist Model." Annals of Internal Medicine. 1999;130:338-342.
3) Whitcomb W. "The Hand-off: Innovation and Solutions for the Continuity between Hospitalists and Referring Physicians." ACP-ASIM Annual Session, April 1999.
4) Craig DE, et al. "Implementation of a Hospitalist System in a Large Health Maintenance Organization: the Kaiser Permanente Experience." Annals of Internal Medicine. 1999; 130: 355-359.
5) Goldman LM. "The Impact of Hospitalists on Medical Education and the Academic Health System." Annals of Internal Medicine. 1999; 130:364-367.
6) Wachter RM, "New Issues in the Hospitalist Movement." ACP-ASIM Annual Session, April 1999.
7) Whitcomb W. "The Hand-off: Innovation and Solutions for the Continuity between Hospitalists and Referring Physicians." ACP-ASIM Annual Session, April 1999.
8) Nolan JP. "Internal Medicine in the Current Health Care Environment: A Need for Reaffirmation." Annals of Internal Medicine. 1998; 128: 857-862.
9) Sox H. "The Hospitalist Model: Perspectives of the Patient, the Internist, and Internal Medicine." Annals of Internal Medicine. 1999;130:368-372.
This article was prepared for the ACP IMG Web site in 2000.
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